1) Transport
e.g. buses, community transport, parking.

What concerns you most about transport?
- please comment in the box below

2) The local environment
e.g. lighting, pavements, graffiti.

What concerns you most about the local environment?
- please comment in the box below

3) Safety in the home and community
e.g. crime, bogus callers, fires, falls.

What concerns you most about safety
in the home and community?
- please comment in the box below

4) Health and social care services
e.g. home, daycare and hospital services,
local healthcare, GP/Dental.

What concerns you most about health & social care services?
- please comment in the box below

 5) Access to local opportunities and facilities
e.g. learning and leisure facilities, social opportunities and facilities.

How do you feel about opportunities in the Gorgie/Dalry area?
- please comment in the box below

Is having a local older people's forum a good idea
- please select one option below

Yes
No
Not Sure

Please comment:

Would you participate in the forum?
- please select one option below

Yes No

If not, what are the main reasons?
- please comment in the box below

Do you need any help to attend if you
would like to participate in the forum?
- For example, hearing/sight/mobility difficulties, language barriers or transport issues. Please outline below:

Please provide any additional relevant information
- Use the box below to add in any information you think is relevant to this survey that has not been covered elsewhere on the form

Please tell us your age group:
- click the age group relevant to you

50 - 60 61 - 70 71 - 80 81 - 90 90 plus

Which ethnic background are you from?
- select from the drop down list provided

please select.. White Asian/Asian British Mixed Black/ Black British Chinese Other

Thank You For Your Time And Assistance!